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Proptosis

(Exophthalmos)

By

Christopher J. Brady

, MD, Wilmer Eye Institute, Retina Division, Johns Hopkins University School of Medicine

Last full review/revision May 2021| Content last modified May 2021
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Etiology of Proptosis

Evaluation of Proptosis

Rate of onset may provide a clue to diagnosis. Sudden unilateral onset suggests intraorbital hemorrhage (which can occur after surgery, retrobulbar injection, or trauma) or inflammation of the orbit or paranasal sinuses. A 2- to 3-week onset suggests chronic inflammation or orbital inflammatory pseudotumor (non-neoplastic cellular infiltration and proliferation); slower onset suggests an orbital tumor.

Ocular examination findings typical of hyperthyroidism but unrelated to infiltrative eye disease include eyelid retraction, eyelid lag, temporal flare of the upper eyelid, and staring. Other signs include eyelid erythema and conjunctival hyperemia. Prolonged exposure of larger-than-usual areas of the eyeball to air causes corneal drying and can lead to infection and ulceration.

Red flags

The following findings are of particular concern:

  • Eye pain or redness

  • Headache

  • Loss of vision

  • Diplopia

  • Fever

  • Pulsating proptosis

  • Neonatal proptosis

Testing

Proptosis can be confirmed with exophthalmometry, which measures the distance between the lateral angle of the bony orbit and the cornea; normal values are < 20 mm in whites and < 22 mm in blacks. CT or MRI of the orbits is often useful to confirm the diagnosis and to identify structural causes of unilateral proptosis. Thyroid function testing is indicated when Graves disease Etiology Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more Etiology is suspected.

Treatment of Proptosis

Lubrication to protect the cornea is required in severe cases. When lubrication is not sufficient, surgery to provide better coverage of the eye surface or to reduce proptosis may be required. Systemic corticosteroids (eg, prednisone 1 mg/kg orally once a day for 1 week, tapered over 1 month) are often helpful in controlling edema and orbital congestion due to thyroid eye disease or inflammatory orbital pseudotumor. Other interventions vary by etiology. Graves exophthalmos is not affected by treatment of the thyroid condition but may lessen over time. Tumors must be surgically removed. Selective embolization or, rarely, trapping procedures may be effective in cases of arteriovenous fistulas involving the cavernous sinus.

Key Points

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Test your knowledge

How to Remove a Foreign Body from the Eye
When treating a patient with a foreign body in the eye, examination of the eye using a slit lamp is appropriate. If at any time during the examination an intraocular foreign body or penetrating injury is suspected, which of the following is the most appropriate next step?
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